Devastating Brain Injury Working Party

by Dan Harvey, Chair, Devastating Brain Injury Working Party

The Faculty of Intensive Care Medicine and Intensive Care Society’s Joint Professional Standards (JPS) committee exists to help develop clinical standards and ensure quality and safe practice. Whilst this includes synthesis of research into evidence based guidelines, it also includes publication of guidance in areas where the evidence base is less certain, but clear risks to either patients or professional practice exist.

the initial prognostication was correct in the vast majority of cases, but critically, not in all

The concerns that resulted from the publication of Manara and colleagues’ recent paper in the Journal of the Intensive Care Society is an example.¹ In summary it described a change in clinical practice in one geographical area, delaying the early withdrawal of therapy from patients considered to have unsurvivable brain injury in the emergency department. Perhaps unsurprisingly to some, the initial prognostication was correct in the vast majority of cases, but critically, not in all. Indeed, Manara and colleagues describe two patients in their initial cohort with good functional outcomes.

This is one area of clinical practice with a high clinical risk, and the implications of changes in practice may be significant. For example, it takes little imagination to see how changes in ICU admission criteria might be applied in other clinical areas. They could change family and staff expectations, or impact on unit and hospital quality metrics to name just a few concerns.

Such guidance can help ICU and ED clinicians establish consensus within their own organisations, marshal resources where necessary, and ultimately protect patient safety

When the evidence base is weak we should at least be able to clearly determine and summarise expert opinion and make it available to consultants on the front line. Such guidance can help ICU and ED clinicians establish consensus within their own organisations, marshal resources where necessary, and ultimately protect patient safety. I would go further and claim (with admittedly little evidence) that the existence of such guidance may protect not only patients, but also their doctors from external criticism of decision making.

A FICM / ICS JSC working party with members from a range of stakeholder professional organisations has drafted guidance on the management of DBI, which is currently out for wider consultation and is expected to be published early in 2017. Such guidance should not replace individualised decision making by patients, their families and their doctors, but seek to ensure that barriers to making decisions in the patients’ best interests are recognised, challenged and removed.

We hope that colleagues will find the guidance useful, and that it will help to bring clarity and consensus to decisions that can be controversial. The JSC would be very keen to listen to feedback specifically on this guidance, but also more widely as to whether guidance within such areas of potential conflict and controversy is useful, and whether the process used to develop it is appropriate.

Manara AR, Thomas I, Harding R. A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries. Journal of the Intensive Care Society 2016;:1–7. doi:10.1177/1751143716647980

Published by A. C. Long

One thought on “Devastating Brain Injury Working Party”

My concern about both the article by Manara, and also this article is that it focuses on the response of the intensivist to the incorrect prognostication by the neurosurgeon. I can think easily in my own experience of 4 cases “written off” by neurosurgeons explicitly, who went to other surgeons, and were treated and made full recoveries. The elephant in the room in these cases are the neurosurgical decisions. I saw no evidence in the Manara paper that the local surgeons had reviewed their practice – I suggest more important to keep the patient alive than to turn them into an organ donor. Surely the first issue is to stop neurosurgeons refusing to treat such patients. I would draw your attention further to the regulation 28 report by Coroner Hassell last year on the subject.